Group psychosocial interventions for anxiety, depression, and post-traumatic stress disorder in children and adolescents in low- and middle-income countries: A realist systematic review and meta-analysis of randomised controlled trials

TL;DR

This study explores how group psychosocial treatments for mental health issues in children and teens work differently in low- and middle-income countries, based on factors like age and culture.

Contribution

The study introduces a realist systematic review approach to understand how and why group psychosocial interventions work in diverse contexts within low- and middle-income countries.

Findings

Group psychosocial interventions significantly reduced symptoms of depression, anxiety, and PTSD in children and adolescents.

Effect sizes were larger for older children and those without conflict exposure, suggesting context influences outcomes.

Programme theories suggest interventions are more effective when culturally adapted and age-appropriate.

Abstract

Group psychosocial interventions can be a scalable treatment for depression, anxiety, and post-traumatic stress disorder (PTSD) in low- and middle-income countries (LMICs) but effects are heterogeneous. Little is known about how intervention mechanisms and context interact to generate different outcomes in different populations. We conducted a realist systematic review, combining traditional systematic review methods with analysis of intervention mechanisms and contextual factors to further understanding of complex interventions. This involved: (i) a scoping review to build initial theory and inform data extraction and analysis; (ii) systematically searching six databases for randomised controlled trials (RCTs) of group psychosocial interventions for participants aged 0–19 years in LMICs (21 November 2022, updated 26 April 2024); (iii) extracting data on outcomes, contextual factors, and intervention mechanisms to build hypotheses about how context interacts with mechanisms to generate outcomes (context-mechanism-outcome configurations; CMOCs); (iv) narratively synthesising CMOCs into wider programme theories about how and why psychosocial interventions work; (v) meta-analyses and meta-regressions to assess trends and test CMOCs. We included 38 RCTs with data for 6,086 participants (52% female, mean age 13). These data informed 14 programme theories including theories that interventions work best when adapted for participant cognitive level, incorporating age-appropriate activities, accounting for local gender-specific issues, and being culturally adapted. Pooled post-intervention effect sizes were -0.72 (95% CI -1.01 to -0.42, p < 0.001) for depression, -0.90 (95% CI -1.57 to -0.23, p = 0.014) for anxiety, and -0.71 (95% CI -1.05 to -0.38, p < 0.001) for PTSD. The only significant results in meta-regressions were larger effect sizes for older children and in populations without exposure to conflict for depression symptoms only. Socio-demographic and contextual factors may influence how interventions work and help to explain the heterogeneity of effects. More high-quality RCTs with moderation and mediation analyses are needed to explore the transferability of these interventions.PROSPERO registration: CRD42022364043.

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